In This Section

Reimbursement Issues

  • CMS regulations
  • Recognition of and reimbursement for nuclear imaging procedures by Medicare and other third-party payers
  • Recognition of and reimbursement for nuclear medicine-related drugs and radiopharmaceuticals
  • Relative value scales and physician reimbursement in general
  • News articles and press releases directly related to reimbursement and/or CMS

When reading materials about reimbursement and coding, always make sure to read the date and type. Reimbursement and coding information modifications by the United States government are extremelyfrequent, so always double check the respective agencies' websites to ensure you have the most current data.

Reimbursement News

  • SNMMI Submits Comments to CMS Regarding CY 2017 Proposed Rules for HOPPS and MPFS
    Sep 1, 2016 — The Society recently submitted comments to the Centers for Medicare and Medicaid Services on two proposed rules.
  • Imaging Drug Development - FDA Regulatory Issues Presentation Available to Members
    Aug 1, 2016 — The society has been given permission by the Food and Drug Administration to share the "Imaging Drug Development - FDA Regulatory Issues" presentation from SNMMI's 2016 Annual Meeting.
  • SNMMI Presents at NRC Stakeholders Meeting
    Jul 27, 2016 — The Society recently presented at a high-level stakeholders meeting on July 26, 2016.
  • FDA Approves New Imaging Agent for Neuroendocrine Tumor Diagnosis
    Jun 2, 2016 — On June 2, Advanced Accelerator Applications (AAA) announced that FDA has approved NETSPOT (Ga-68-labeled DOTATATE injection) for the localization of somatostatin receptor–positive neuroendocrine tumors (NETs) in adult and pediatric patients.
  • FDA Approves New PET Imaging Agent for Recurrent Prostate Cancer
    May 31, 2016 — Today Blue Earth Diagnostics announced that the FDA has approved Axumin (F-18-labeled fluciclovine injection) for detecting biochemical recurrence of prostate cancer. It is the first FDA-approved F-18-labeled PET imaging agent for use in patients with suspected recurrent prostate cancer.
  • SNMMI Clinical Trials Network Co-sponsors Workshop with NCI
    May 17, 2016 — SNMMI's Clinical Trials Network sponsored a workshop with the National Cancer Institute titled Immune Modulation Therapy and Imaging: What can we do in clinical trials now? A full video webcast is available.
  • Free IDEAS Study Webinar:
    The Nuts and Bolts of Medicare Imaging Reimbursement in the IDEAS Study
    Apr 29, 2016 — This session, presented Tuesday, May 24, by Denise Merlino, will review the Medicare billing guidance for the coverage with evidence development study called IDEAS.
  • Thomas Hope and Prashant Jolepalem Chosen as Recipients of the 2016 Henkin Fellowship
    Mar 1, 2016 — SNMMI and the Education and Research Foundation for Nuclear Medicine and Molecular Imaging are pleased to announce that Thomas Hope, MD, and Prashant Jolepalem, MD, CCD, are the recipients of the 2016 Robert E. Henkin Government Relations Fellowship.
  • Cardiologist Nominated to Be Head of FDA
    Feb 25, 2016 — On Tuesday February 24, the Obama administration nominated Dr. Robert Califf, a cardiologist and clinical researcher long affiliated with Duke University, to be the commissioner of the Food and Drug Administration.
  • SNMMI Comments on USP General Chapter 797 Pharmaceutical Compounding
    Feb 24, 2016 — On February 24, 2016, SNMMI submitted comments to USP on General Chapter 797 Pharmaceutical Compounding - Sterile Preparations.
  • The Joint Commission Revises Standards for Diagnostic Imaging Services
    Feb 17, 2016 — On February 16, 2016, the Joint Commission (TJC) approved new Standards for Diagnostic Imaging Services for hospitals, critical access hospitals, and ambulatory care organizations. Effective September 1, 2016.
  • SNMMI Submits Comments to NRC on I-131 Patient Release
    Feb 16, 2016 — On Tuesday, February 16, SNMMI submitted comments to the U.S. Nuclear Regulatory Commission (NRC) on a number of issues associated with medical treatment of patients with sodium iodide I–131.
  • NIST Revises Primary Standard for Radium-223 (Ra-223)
    Jan 21, 2016 — NRC has issued an information notice to alert addressees that the National Institute of Standards and Technology revised its primary standard for radium-223 and convey the impact this revision will have on the calibration of patient doses of Ra-223 dichloride (trade name Xofigo®).
  • SNMMI Submits Comments to CMS Regarding CY 2016 Final Rules for HOPPS and MPFS
    Dec 16, 2015 — On Wednesday, December 16, SNMMI submitted comments to CMS on the CY 2016 Final Rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule (MPFS).
  • USP Call for Candidates: Radioactive Drugs Expert Panel
    Nov 30, 2015 — The US Pharmacopeia (USP) is currently in the process of forming a Radioactive Drugs Expert Panel. The call for members of this Panel is now open and the deadline to apply is December 20th.
  • NRC Seeks Information Regarding I-131 Patient Release
    Nov 16, 2015 — The U.S. Nuclear Regulatory Commission is seeking information from the public regarding sodium iodine-131 patient release practices and standards.
  • CMS Releases CY 2016 HOPPS & MPFS Final Rules - Effective January 1, 2016
    Nov 11, 2015 — On October 30, CMS released the CY 2015 Final Rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule.
  • USP Seeking Comments on General Chapter Revisions: Deadline approaching!
    Nov 9, 2015 — The US Pharmacopeia (USP) is currently in the process of revising several general chapters that are important to the nuclear medicine community.
  • CMS Creates Modifier to Enforce XR-29 Radiation Dose Penalties
    Nov 9, 2015 — The Protecting Access to Medicare Act (PAMA) established radiation dose requirements that will take effect on January 1, 2016.
  • Bipartisan Budget Agreement - Hospital Outpatient Payment Change Included
    Oct 30, 2015 — Lawmakers have negotiated an agreement on a two-year budget package which would lift federal spending caps for two years, increasing discretionary spending by $80 billion.
  • SNMMI Submits Comments on CMS Proposed Decision Memo for NaF-18 PET
    Oct 16, 2015 — SNMMI submitted comments to CMS regarding the Proposed Decision Memo on Positron Emission Tomography (NaF-18) to identify bone metastasis of cancer.
  • SNMMI's 2015 Patient Advocacy Hill Day
    Oct 1, 2015 — On Monday, September 28, 2015, SNMMI, patient advocates, and members of the Patient Advocacy Advisory Board, met with 42 Congressional offices for SNMMI's 2015 Patient Hill Day.
  • CMS News: MACRA - New Opportunities
    Sep 29, 2015 — CMS released a Request for Information (RFI) to seek public comment related to new provisions in the Medicare Access and CHIP Reauthorization Act of 2015.
  • SNMMI Submits Comments to CMS Regarding CY 2016 Proposed Rules for HOPPS and MPFS
    Aug 26, 2015 — On Wednesday, August 26, SNMMI submitted comments to CMS on the CY 2016 Proposed Rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule (MPFS).
  • CMS & AMA Announce Efforts to Help Providers Prepare For ICD-10
    Jul 7, 2015 — On July 6, CMS and the AMA announced efforts to help providers prepare to transition from ICD-9 to ICD-10 coding.
  • CMS Releases the CY 2016 HOPPS Proposed Rule
    Jul 2, 2015 — On July 1, 2015, CMS released the CY 2016 Hospital Outpatient Prospective Payment System proposed rule.
  • SNMMI Releases Executive Summary from FDA Stakeholder Meeting
    May 20, 2015 — SNMMI finalized its executive summary of the broad FDA Stakeholder meeting held in the fall of 2014.
  • President Signs Legislation to Replace the SGR
    Apr 16, 2015 — On April 16, President Obama signed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015. This legislation will replace Medicare's SGR formula before CMS begins processing a 21% cut to physician reimbursements.
  • SNMMI Submits Comments on Ending Data Collection for NaF-18 PET
    Apr 8, 2015 — SNMMI submitted comments to CMS regarding NOPR's request to reconsider a national coverage policy for positron emission tomography (18F-NaF PET) to identify bone metastasis of cancer.
  • Congress Adjourns for Spring Recess Without Passing SGR Legislation
    Mar 30, 2015 — Congress adjourned for their spring recess without passing legislation that would permanently repeal Medicare's sustainable growth rate (SGR) and provide incentives for doctors to focus on value-driven care.
  • Congress Introduces New SGR Repeal Legislation
    Mar 19, 2015 — Congress has introduced bipartisan, bicameral legislation would permanently repeal Medicare's sustainable growth rate (SGR) and provide incentives for doctors to focus on value-driven care.
  • CMS Requests Comments on Ending Data Collection for NaF-18 PET
    Mar 18, 2015 — CMS has solicited public comments regarding NOPR's request to end the prospective data collection requirements under CED for use of NaF-18 PET imaging in intended patient management.
  • Deadline Looms for SGR Appeal
    Mar 11, 2015 — With the year-long patch set to expire on April 1, 2015, Congress must pass SGR legislation to prevent a 21 percent pay cut to Medicare physicians.
  • SNMMI Submits Comments to CMS for CY2015 HOPPS & MPFS Final Rules
    Jan 6, 2015 — SNMMI submitted comments to CMS regarding the CY15 Final Rules for HOPPS and MPFS. Both rules were due no later than 5pm ET on Wednesday, December 31, 2014.
  • SNMMI Comments on NRC Part 35 and Part 20 Rules
    Nov 21, 2014 — The Society recently submitted comments on NRC 10 CFR Part 35 and Part 20.
  • CMS Releases CY 2015 HOPPS & MPFS Final Rules
    Oct 31, 2014 — On October 31, CMS released the CY 2015 Final Rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule.
  • Highlights of SNMMI’s FDA Stakeholder Meeting
    Oct 30, 2014 — On October 27, 2014, SNMMI hosted a broad stakeholder meeting in Linthicum Heights, Md. The society brought in more than 40 experts from the field of nuclear medicine and molecular imaging to discuss the current regulatory climate.
  • SNMMI Submits Comments to TJC
    Oct 17, 2014 — On October 17, SNMMI submitted comments to The Joint Committee (TJC) regarding proposed revisions to diagnostic imaging services.
  • Mallinckrodt to Increase Prices
    Oct 13, 2014 — Mallinckrodt informed customers that, due to some of the significant cost drivers that the nuclear medicine industry is experiencing, they will be increasing prices over the next several years.
  • Upcoming Freeze on Claims for FDG PET for Solid Tumors
    Oct 6, 2014 — CMS has announced a temporary processing freeze on claims submitted for FDG PET for Solid Tumors between October 6 and November 10.
  • Update on Kinevac Availability
    Sep 17, 2014 — Bracco Diagnostics Inc. announced that production is moving forward with targeted efforts for Kinevac commercial availability by the end of September.
  • Upcoming Webinar: Oncologic PET Coding & Reimbursement
    Aug 20, 2014 — On September 23, 2014, Merlino Health Care Consulting Corp. will hold the webinar "Oncologic PET Coding & Reimbursement, Where Are We Today?"
  • CMS Releases CY 2015 Hospital Outpatient Prospective Payment System Proposed Rule
    Jul 3, 2014 — On July 3, 2014, CMS released the CY 2015 HOPPS proposed rule.
  • CMS Releases CY 2015 Medicare Physician Fee Schedule Proposed Rule
    Jul 3, 2014 — On July 3, 2014, CMS issued a proposed rule that would update payment policies and payment rates for services furnished under the MPFS on or after Jan. 1, 2015.
  • CMS Releases Instructions Related to the NCD to End the Coverage with Evidence Development Requirement for FDG PET for Solid Tumors
    Jul 1, 2014 — CMS has released instructions to Medicare Administrative Contractors regarding the processing of claims pursuant to the June 11, 2013 final decision to end the coverage with evidence development (CED) requirement for certain FDG PET studies for solid tumors.
  • CMS Releases Final Rule Concerning Direct Supervision
    May 8, 2014 — On May 7, 2014, CMS released the Final Rule for Part II Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction. This new rule finalized the previously proposed change of removing the term “direct" from the current requirement at § 482.53(b)(1).
  • SNMMI Releases Q&A Regarding the Price Increase for Macroaggregated Albumin (MAA)
    Apr 23, 2014 — SNMMI has released a Coding Corner Q&A in response to the drastic price increase that went into effect on April 1, 2014 for macroaggregated albumin (MAA).
  • CMS Releases Instructions on the NCD for Beta Amyloid PET in Dementia and Neurodegenerative Disease
    Feb 24, 2014 — CMS has released instructions to contractors related to its National Coverage Determination for Beta Amyloid PET in Dementia and Neurodegenerative Disease.
  • SNMMI Submits Comments to CMS on CY 2014 HOPPS & MPFS Final Rules
    Jan 29, 2014 — On January 27, SNMMI submitted comments to CMS on the CY 2014 HOPPS & MPFS Final Rules.
  • CMS Edits on the Ordering/Referring Providers in Medicare
    Nov 27, 2013 — If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare.
  • CMS Releases CY2014 Medicare Physician Fee Schedule Final Rule
    Nov 27, 2013 — On November 27, 2013, CMS finalized updates to payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule.
  • CMS Releases CY2014 Hospital Outpatient Prospective Payment System Final Rule
    Nov 27, 2013 — On November 27, 2013, CMS issued the final Calendar Year 2014 HOPPS and Ambulatory Surgical Center Payment System Policy Changes and Payment Rates final rule.
  • Medicare Claims for FDG PET Studies with DOS
    Oct 9, 2013 — Effective June 11, 2013, CMS ended the coverage with evidence development (CED) requirement for F-18 fluorodeoxyglucose positron emission tomography (FDG PET) and FDG PET/CT for all oncologic indications contained in section 220.6.17 of the Medicare National Coverage Determinations (NCD) Manual.
  • SNMMI Submits Comments to CMS Regarding CY 2014 Proposed Rules for HOPPS and MPFS
    Sep 6, 2013 — On Friday, September 6, SNMMI submitted comments to CMS on the CY 2014 Proposed Rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule (MPFS).
  • CMS Releases CY2014 Hospital Outpatient Prospective Payment System Proposed Rule
    Jul 9, 2013 — More than 4,000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals are paid under the OPPS. There are approximately 5,000 Medicare-participating ASCs paid under the ASC payment system.
  • FDG Positron Emission Tomography for Solid Tumors and Myeloma: Data Collection Ends Under the National Oncologic PET Registry
    Jul 9, 2013 — Effective June 11, 2013, CMS ended the coverage with evidence development (CED) requirement for F-18 fluorodeoxyglucose positron emission tomography (FDG PET) and FDG PET/CT for all oncologic indications contained in section 220.6.17 of the Medicare National Coverage Determinations (NCD) Manual.
  • CMS Releases CY2014 Medicare Physician Fee Schedule Proposed Rule
    Jul 8, 2013 — On July 8, 2013, CMS issued a proposed rule that would update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2014.
  • Updated: Complimentary Webinar for Positron Emission Tomography Imaging for Solid Tumors
    Jul 2, 2013 — SNMMI held a webinar to review and discuss the Centers for Medicare & Medicaid Services (CMS) final PET coverage decision to end coverage with evidence development (CED) for NOPR-covered FDG PET indications (CAG-00181R4), that was released on Tuesday, June 11th, 2013.
  • CMS Releases Final Decision Memo for Positron Emission Tomography (FDG) for Solid Tumors
    Jun 11, 2013 — Today CMS posted a final decision to end the coverage with evidence development requirement for FDG PET for solid tumors (CAG-00181R4).
  • AMA CPT Category III Codes Effective on July 1, 2013
    Jun 3, 2013 — The 2013-14 Current Procedural Terminology (CPT) electronic Category III file was released by the American Medical Association (AMA) on December 27, 2012.
  • CMS Posts the Final Decision Memo of the PET NCA Reconsideration
    Mar 8, 2013 — On Thursday, March 7, the Centers for Medicare & Medicaid Services (CMS) posted a final decision memo for positron emission tomography (PET).
  • CMS HCPCS Level II Codes Effective January 1, 2013
    Nov 27, 2012 — The 2013 Healthcare Common Procedure Coding System (HCPCS) electronic file has been posted with updated file information on the Centers for Medicare and Medicaid Services (CMS) web site.
  • CMS Issues CY 2013 HOPPS Final Rule
    Nov 2, 2012 — The Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) rule on November 1, 2012, updating Medicare payment policies and rates for hospital outpatient and ASC services beginning January 1, 2013.
  • CMS Issues CY 2013 Physician Fee Schedule Final Rule
    Nov 2, 2012 — The Centers for Medicare & Medicaid Services (CMS) today issued a final rule for the Medicare Physician Fee Schedule.
  • SNMMI Submits Comments on Proposed Medicare Physician Fee Schedule Rules for CY 2013
    Sep 4, 2012 — SNMMI has submitted comments to the Centers for Medicare and Medicaid Services regarding the CY 2013 proposed rules for the Medicare Physician Fee Schedule.
  • SNMMI Submits Comments on Proposed Hospital Outpatient Prospective Payment System Rules for CY 2013
    Sep 4, 2012 — SNMMI has submitted comments to the Centers for Medicare and Medicaid Services regarding the CY 2013 proposed rules for the Hospital Outpatient Prospective Payment System.
  • CMS Issues CY 2013 Physician Fee Schedule Proposed Rule
    Jul 6, 2012 — The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would increase payments to family physicians by approximately 7 percent and other practitioners providing primary care services between 3 and 5 percent.
  • CMS Issues CY 2013 Hospital Outpatient Prospective Payment System Proposed Rule
    Jul 6, 2012 — The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would update payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) beginning Jan. 1, 2013.
  • CMS Issues Proposed Rule for Reporting and Returning of Overpayments
    Feb 23, 2012 — CMS has issued a proposed rule implementing the requirements for reporting and returning overpayments set forth in the Affordable Care Act.
  • CMS Issues New POS Guidance
    Feb 21, 2012 — The Centers for Medicare & Medicaid Services (CMS) has provided new Place of Service (POS) guidance in Change Request (CR) 7631 (Transmittal 2407) effective on April 1, 2012.
  • Congress Passes 10 Month SGR Fix
    Feb 17, 2012 — Late Friday morning, the House of Representatives (293-132) and the Senate (60-36) passed the bipartisan agreement on legislation to extend the payroll tax holiday through the end of the year.
  • HHS Announces Intent to Delay ICD-10 Compliance Date
    Feb 16, 2012 — Health and Human Services Secretary Kathleen G. Sebelius announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).
  • New ICD-9-CM Volume 1, 2 Diagnosis Codes
    Jan 11, 2012 — The ICD-9-CM diagnosis code; 793.1 - Non specific (abnormal) findings on radiological and other examination of body structure; lung field, is frequently reported on FDG PET scan claims when PET is performed prior to biopsy for diagnosis of lung cancer in patients with lung masses, solitary pulmonary nodules and multiple pulmonary nodules.
  • CMS HCPCS Level II Codes Effective January 1, 2012
    Jan 9, 2012 — The 2012 Healthcare Common Procedure Coding System (HCPCS) electronic file has been posted with updated file information on the Centers for Medicare and Medicaid Services (CMS) web site.